Use of calcium hydroxylapatite in the upper third of the face: Retrospective analysis of techniques, dilutions and adverse events

Dimension, Location and Clinical Importance of Supraorbital Foramen and Notch: A Combined Cadaveric and Dry Skull Study

PURPOSE

The exit points of the supraorbital nerve and its branches hold significant importance in various medical procedures, including supraorbital endoscopic surgeries, forehead-facial aesthetic plastic surgeries, medical aesthetic applications and maxillofacial surgeries. Therefore, the primary objective of the present study was to precisely define the dimension, location and clinical significance of the supraorbital foramen/notch. By doing so, we aimed to enhance our understanding of this anatomical structure and its implications for surgical and aesthetic interventions in the supraorbital region.

METHODS

For our study, we conducted anatomical dissections and bone measurements to assess the significance of anatomical variations of the supraorbital foramen/notch. We utilized a sample consisting of 28 cadavers and 38 skulls. The supraorbital foramen/notch was bilaterally analyzed in all 28 cadavers and 38 dry bones. We morphometrically analyzed the distance between the supraorbital foramen/notch and various anatomical landmarks, including the nasion, supraorbital margin, infraorbital margin, temporal crest, glabella, frontal cavity and midline of the face. Additionally, we measured the distance between the supraorbital foramen/notches and the frontal foramen/notches, and the width of the supraorbital foramen/notch and the distance between both supraorbital foramina/notches.

RESULTS

There are 32 (57.14%) supraorbital  foramina, and the remaining are 24 (42.86%) supraorbital notches in cadavers and there are 36 (47.37%) supraorbital foramina, and the remaining are 40 (52.63%) supraorbital notches in skulls. We observed consistency in the dimension and location values of anatomical measurement parameters between cadavers and dry skulls on both right and left sides, with the exception of the parameter "distance from temporal crest" (p=0.042). Furthermore, our correlation analysis revealed a significant positive relationship between the right and left sides across all parameters, except for the following instances: in dry skulls, "distance from supraorbital margin" and in cadaver parameters, "distance from temporal crest, " "distance from frontal cavity" and "width."

CONCLUSION

In our study, we observed that the distributions of supraorbital foramina and notches were nearly similar. Furthermore, our findings indicated comparable measurements between the right and left sides in both cadavers and skulls. These results suggest a degree of consistency in supraorbital anatomy within our study sample, regardless of the specimen type (cadavers or skulls) or laterality (right or left side).

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Combined Approach Using IncobotulinumtoxinA and CPM-Hyaluronic Acid Injections for the Periorbital Complex Improvement: A Pilot Study

Background

Previous reports have objectively demonstrated the efficacy of botulinum toxin for brow elevation. No previous clinical trial has reported a combined approach to botulinum toxin A injection with hyaluronic acid (HA) injection in the upper face for periorbital region beautification focusing on eyebrow reshaping.

Objectives

To evaluate the effect of IncobotulinumtoxinA injection using the ONE21 technique combined with HA injection (CPM technology) to redefine brow shape and position.

Methods

A prospective pilot study was designed to evaluate the effect of IncobotulinumtoxinA injection using the ONE21 technique-with a preestablished scheme of doses and injection-site distribution-combined with HA injection (CPM technology) periosteally into the palpebromalar groove and subdermally in the anterior temporal region, to redefine brow shape and position. Objective eyebrow measurements were taken by an independent investigator using the Merz Aesthetic Scale (MAS) for brow positioning. Patient satisfaction was also evaluated. Some patients were also assessed using the Vectra System (Canfield Scientific, Parsippany, NJ).

Results

Eleven females, aged 29 to 55 years, were included in this prospective pilot study. The totality of patients (11/100%) had at least ≥1-point improvement in the MAS brow positioning. All patients (100%) reported significant aesthetic improvement of their periorbital region and appearance, with 82% of the patients much improved. Mild side effects, such as ecchymosis and transient temporal edema, were reported.

Conclusions

The combined technique improved the appearance of the orbital area by uplifting the lateral eyebrow and creating an almond-shaped eye effect, which characterizes the trending marketing term Foxy eyes. Further studies, including more cases, are needed to obtain a statistically significant outcome.

Level of Evidence 4

Safety of the inferolateral orbital access for filling the temporal region with the fanning technique

INTRODUCTION

The anatomical complexity of the temporal region makes it so treatments with fill-ins are challenging due to high vascular risk. Techniques which provide safer procedures must be encouraged.

GOAL

Suggest access to the temple through the inferolateral orbital region as a means for safer temporal fill-ins.

METHODS

The fanning technique was plotted out not only via the conventional access (pretragal) but via the proposed one as well. The superficial temporal artery (STA) was mapped with ultrasound. The angles for each of the five retroinjection vectors were calculated in relation to STA and their mean was extracted. The longitudinality of the vector in regard to the vessel was considered the least safe factor.

RESULTS

The mean injection angle towards the artery was a 35-degree angle for the conventional access technique and a 73-degree angle for the inferior-lateral orbital access technique (p < 0.05). The more a degree is tangential to the vessel, the higher the chances for inadvertent puncture due to small technical issues. The safety of the procedure through the inferolateral orbital access is corroborated with blind ultrasound imaging done in real-time by radiologists.

CONCLUSION

The suggested access is shown to be comparably safer from a vascular perspective than the conventional pretragal access.

Complications of Nonpermanent Facial Fillers: A Systematic Review

Background:

A variety of complications after injection of nonpermanent fillers for facial rejuvenation have been reported so far. However, to date, the overall complication rate is still a matter of debate. The aim of this study was to perform a systematic review of literature to assess the type and severity of associated complications following injections in different anatomical regions of the face.

Methods:

The entire PubMed/Medline database was screened to identify case reports and clinical studies describing complications that have occurred after injection of nonpermanent fillers in the face. These complications have been reviewed and analyzed according to their occurrence in different anatomical regions of the face.

Results:

Forty-six articles including a total of 164 patients reported on a total of 436 complications during the time period between January 2003 and February 2020. The majority of the complications were reported after injections to the nose and the nasolabial fold (n = 230), the forehead and the eyebrows (n = 53), and the glabellar region (n = 36). Out of 436 complications, 163 have been classified as severe or permanent including skin necrosis (n = 46), loss of vision (n = 35), or encephalitis (n = 1), whereas 273 complications were classified as mild or transient, such as local edema (n = 74), skin erythema (n = 69), and filler migration (n = 2). The most severe complications were observed in treatments of nose, glabella, and forehead.

Conclusions:

Nonpermanent facial fillers are associated with rare but potentially severe complications. Severity and impact of complications depend on the anatomical region of the face and eventually require profound knowledge of facial anatomy.

Enhancing the Lateral Orbital "C-Angle" With Calcium Hydroxylapatite: An Anatomic and Clinical Study

BACKGROUND

Deliberate injection of specific facial subunits may improve aesthetic outcomes in facial rejuvenation. We contend that the lateral orbital area (LOA) is a key anatomic subunit in the perception of eye attractiveness, with a C-shaped distribution of fat contributing to the formation of a distinct angle in the lateral orbit.

OBJECTIVES

The aim of this study was to describe the anatomy of the LOA that constitutes the C-shaped angle and to investigate the safety and cosmetic outcomes of nonsurgical enhancement of that area with calcium hydroxylapatite (CaHA).

METHODS

Four injected fresh-frozen cadaver heads were dissected. Twenty patients were enrolled in a prospective clinical study. Participants were seen on the day of injection, and at 2 weeks and 3 months postinjection. Two-dimensional and 3D photographs were analyzed to quantify the volumetric changes between pretreatment and postinjection time points. Secondary outcomes included Global Aesthetic Improvement Scale score and subject satisfaction at 3 months.

RESULTS

Cadaver dissections revealed distinct fat compartments and a zone of adhesion forming the C-shaped area around the lateral orbit. In the clinical study, a mean of 1.88 mL of CaHA was injected into each lateral periorbital region. There was 97% and 76% volume retention at 2 weeks and 3 months, respectively, with 70% of patients being "very satisfied" at 3 months. The average Global Aesthetic Improvement Scale rating at 3 months was 3.95. There were no complications.

CONCLUSIONS

The LOA is a distinct facial subunit that can be enhanced safely by CaHA injection with good cosmetic outcomes. Focusing on the C-angle can improve periorbital aesthetics.

LEVEL OF EVIDENCE: 4

Intraarterial Degradation of Calcium Hydroxylapatite Using Sodium Thiosulfate - An In Vitro and Cadaveric Study

BACKGROUND

The most severe complications following soft tissue filler injections result from the intraarterial administration of the filler product. Although hyaluronic acid-based filler can be trans-arterially dissolved with hyaluronidase, no information is available on calcium hydroxylapatite (CaHA)-based fillers.

OBJECTIVE

The authors sought to test whether CaHA-based fillers can be trans-arterially dissolved by sodium thiosulfate (STS) when evaluated in cadaveric and in vitro models.

METHODS

Human cadaveric facial arterial segments were each filled with 0.2 cc of commercially available CaHA product and submerged for 24 hours in 4 different STS-containing solutions: 10 cc STS (300 mg/cc) (pure, 1:1 dilution, 1:2 dilution), 0.9% saline and 10 cc STS (300 mg/cc), and 300 IU (bovine) hyaluronidase in a 1:1 ratio.

RESULTS

Intraarterial CaHA was detected in human facial artery segments after 24 hours independent of the STS concentration employed. Submerging the arterial segments in STS (300 mg/cc) and 300 IU (bovine) hyaluronidase (1:1 ratio) also did not dissolve the intraarterial CaHA product. Gray scale analyses did show, however, that increasing concentrations of STS resulted in increased disintegration of CaHA in an in vitro experimental setting.

CONCLUSIONS

The results of this study indicate that STS is limited in its potential to dissolve intraarterial CaHA of cadaveric human facial arteries, despite the fact that it appears effective when in direct contact with the CaHA. Adverse events caused by intraarterial administration of CaHA-based fillers still lack a suitable antidote.

The use of periocular fillers in aesthetic medicine

The periocular area is the first to display signs of ageing. Dermal fillers are an increasingly popular, minimally invasive method for facial rejuvenation. The eye is anatomically delicate and complex. Therefore, special consideration must be taken if dermal fillers are employed. This article examines the literature to assess the efficacy and safety of dermal fillers around the eye as well as the management of complications secondary to dermal filler use, such as oedema, granuloma formation, filler migration, xanthelasma, skin necrosis and visual loss. Hyaluronic acid (HA) is the most popular and commonly employed dermal filler for periocular use. It is effective, with good observer improvement and patient satisfaction (p<0.0001). Ninety percent of adverse events are mild in nature and self-resolve within 1 month. Malar oedema is a delayed complication unique to the periocular area, occurring in 11% of patients. This can be managed with use of hyaluronidase if a HA filler has been employed. Other complications, such as granuloma formation, filler migration and xanthelasma, have also been reported with variable management outcomes. Vascular adverse events include skin necrosis and visual loss. No Level 1 evidence exists for the management of visual loss. Two cases of visual restoration have been identified in the literature; however, this is rare.

Managing intravascular complications following treatment with calcium hydroxylapatite: An expert consensus

BACKGROUND

Inadvertent intra-arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra-arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence-based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA.

METHODS

An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra-arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature.

RESULTS

For prevention of intra-arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow-up treatment. A separate section details the treatment options for open and closed wounds.

CONCLUSIONS

All physicians should be prepared for the eventuality of intra-arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up-to-date office-based protocol for the prevention and treatment of complications arising from intra-arterial CaHA injection.